Synopsis In the early morning hours of 11February 1995, the PACIFIC BANDIT, laden with about 23,000kg of fish, was off the west coast of Vancouver Island, British Columbia, not engaged in fishing operations. The wind and sea conditions were such that the vessel was shipping and retaining seas on the main deck. The vessel listed to starboard, downflooded, capsized, and eventually sank. Two crew members were swept overboard; the other two abandoned the vessel and managed to board the liferaft. Three of the crew members were later rescued and one person, who was in the water without a lifejacket or an immersion suit, succumbed to hypothermia and drowned. The Board determined that, while operating in moderate sea conditions, the PACIFICBANDIT capsized when positive transverse stability was lost due to the cumulative effect of the shipped seas retained on deck, the stowage of the catch, the free surface effect of liquids, and downflooding to the below-deck spaces. The open weathertight doors and the broken galley windows accelerated the downflooding, which continued until the vessel lost all reserve buoyancy and sank. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The PACIFIC BANDIT was of welded steel construction with a raised forecastle deck. The forecastle space provided accommodation for three crew members. Access to the space was by way of a door on the centre line at the break of the forecastle. The steel cabin/wheel-house, situated abaft amidship, contained the skipper's cabin, bridge, galley and washroom. Three doors in the after end provided access to (from starboard to port) the washroom, the engine-room and the accommodation area. The accommodation entry door was a dutch door, comprising two sections designed such that the upper half could be secured in the open position while the lower half could be secured in the closed position. A net drum and two trawl winches were positioned on the afterdeck, abaft the wheel-house. 1.2 History of the Voyage After partially replenishing fuel, and with a catch of some 22,700kg of fish on board, the PACIFIC BANDIT departed Ucluelet, B.C. at about 1630(3) , 10February 1995, for the fishing grounds 30 miles south-west of Amphitrite Point, B.C. The paravane stabilizers had been deployed to dampen the vessel's roll. Weather conditions were described as good with moderate north-westerly winds and 1 to 2m seas from the north-west. At about 2100, a set was made, and at 2300, the gear was hauled on board. There was only a small amount of fish in the net. The crew sorted the catch, then opened the small access hatch in the forward fish hold hatch cover and dumped the catch into the hold. The access hatch cover was then closed but not secured. After securing the gear and tidying up, the cook/deck-hand (hereinafter referred to as the cook) and the deck-hand retired to the forecastle. The skipper advised the engineer/deck-hand (hereinafter referred to as the engineer) to steam slowly in a southerly direction toward a way-point eight miles from the vessel's present position, then to turn around and head north. The skipper then went to bed. Reportedly, the vessel had a freeboard of 150mm aft and 450mm forward. At about 0100, the engineer called the cook to take over the watch. The engineer briefed the cook on the vessel's position and on the skipper's instructions, then retired to his cabin in the forecastle accommodation. The vessel was operating in a following wind and sea for over two hours, during which period about 75mm to 100mm of sea water accumulated on the afterdeck on a more or less continuous basis. At about 0350, the vessel was heading in a southerly direction with a following sea. The cook, who was alone on watch, checked the vessel's position and altered course to starboard to bring the vessel's head into the northerly swell. The skipper, awakened by the vessel's motion, entered the wheel-house. At about the same time, the low water alarm for the main and auxiliary engines' cooling water system sounded. Using the intercom, the skipper instructed the engineer to check the alarm. The engineer alerted the deck-hand and both left the forecastle accommodation. They stepped onto the main deck and found that about 0.5m of sea water had accumulated on the starboard side. Both the skipper and the engineer observed that the vessel had a starboard list of about 10 degrees. The engineer and the deck-hand made their way aft and entered the accommodation area. The engineer started the auxiliary engine from the wheel-house. He then entered the engine-room, opened the valves to the appropriatecompartments, activated the pump, and pumped out the forward fish hold and the engine-room bilges; about 300mm of water was observed in the engine-room bilge. Reportedly, the skipper had planned to fish in the area the following morning to top up the fish hold, weather permitting. However, as the weather had deteriorated, the vessel's course was altered to a north-easterly direction, to head toward Tofino, B.C. With the swell now on the vessel's port bow, the shipped sea water was not clearing from the deck rapidly, so the skipper sent the cook and the deck-hand forward to remove the poundboards near the large freeing ports (locally referred to as scuppers). The poundboards were dismantled, then thrown into the forward fish hold by way of the access hatch, and the cover was closed. The cook and the deck-hand then entered the forecastle and removed their wet clothing and rubber boots. They exited the compartment about 10 minutes later. The doors to the forecastle and after accommodations were in the open position. By that time, the starboard list had increased to 20to 30degrees and sea water was downflooding into the forecastle through the open forecastle door. With the deck awash, the cook and deck-hand went forward and cut loose some poly floats. Meanwhile, the engineer checked the vacuum gauge for the forward fish hold--it indicated that the compartment was dry. He disengaged the pump, closed the valves, and left the engine-room when the starboard list suddenly increased. On his way to the wheel-house, he picked up his personal immersion suit from the cabin and donned it. The skipper put the helm hard-a-port and increased engine rpm in an attempt to buy time; however, the list increased and the deck-hand and cook were swept overboard by a large wave breaking on the foredeck. At 0432, the skipper transmitted MAYDAY messages to Tofino Vessel Traffic Centre (VTC) on channel 74 and to fishing vessels in the area on channel 8 of the very high frequency radiotelephone (VHFR/T). The MAYDAY messages were immediately responded to by the VTC and several other vessels in the area. When two starboard galley windows were broken by the heavy seas and sea water was rapidly flooding the accommodation through open doors, the skipper decided to abandon ship. Meanwhile, the engineer had climbed up on the cabin roof and, after experiencing some difficulties, managed to cut the inflatable liferaft lashings. When the vessel was on her beam-ends, the engineer launched the liferaft by kicking it free of the vessel. The skipper made his way aft through the water, surfaced near the liferaft canister, and hauled on the painter. A short time later, the liferaft inflated on top of him. The engineer was the first to board the liferaft. When the skipper resurfaced, the engineer helped him aboard. They heard the other two crew members on the far side of the capsized vessel and called out to them; however, they could not see them in the darkness. The liferaft was still tied to the vessel. The skipper, fearing that the capsized vessel would sink and take the raft with her, searched for a knife to cut the painter. He could not find it in the darkness; the skipper and the engineer had to chew through the painter to release the liferaft. They then attempted to reach the other survivors, but the wind caused the liferaft to drift away. Meanwhile, the deck-hand and the cook, who were lightly clad and in the water, managed to hold on to some planks, albeit with great difficulty due to the conditions. They tried to paddle toward the capsized vessel but were unable to reach her. The vessel eventually sank in approximate position 4838'N, 12610'W, in 300m of water. A short time later, the deck-hand lost his grip on the planks. The cook held on to him, but the sea washed the deck-hand from his grasp, and the deck-hand disappeared into the darkness. 1.3 Search and Rescue Upon receipt of the MAYDAY transmission, the VTC notified the Rescue Coordination Centre (RCC) Victoria, thus initiating official Search and Rescue (SAR) response. The RCC coordinated the search utilizing four air units, two primary marine SAR units, and a number of fishing and commercial vessels. The SAR air units located three survivors and directed the surface craft which rescued them at about 0715. 1.4 Injuries to Persons The survivors were suffering from mild to severe hypothermia when rescued. They were transported to a hospital, treated, and later released. The deck-hand is still missing and presumed drowned. 1.5 Damage to the Vessel The vessel sank and has been declared a total loss. 1.6 Vessel Certification The PACIFIC BANDIT had been inspected by the Ship Safety Branch (SSB) of the Canadian Coast Guard (CCG) on 17June 1994, and a SIC29 was issued for a full-term period, due to expire on 26May 1998. 1.7 Personnel Certification, Training and History Crew certification is not required on a fishing vessel of less than 100 tons gross tonnage such as the PACIFIC BANDIT. Only the engineer had taken the Marine Emergency Duties (MED) program as a prerequisite to obtaining a Fishing Master, ClassIII Certificate of Competency. The program provides training in life-saving, abandonment, fire-fighting, and first aid, with the use of appropriate equipment. There is at present no regulatory requirement for uncertificated crews of fishing vessels to undergo MED training. This was the engineer's third trip on the PACIFICBANDIT. The skipper is an experienced fisherman who had been intermittently employed as skipper on the PACIFIC BANDIT since August 1994. The cook began fishing in 1986, and this was his third trip on the PACIFIC BANDIT. The deck-hand was new to the fishing industry, and this was his third trip on the PACIFICBANDIT. 1.8 Stability Requirement The PACIFIC BANDIT had not been inclined and no stability data had been generated. There was no regulatory requirement for such stability data. No stability data was available from any source to permit stability analysis, nor were the vessel's plans available. 1.8.1 Crew Observations--Roll Period The survivors reported that the vessel was heavily laden, and the period of roll was described variously as nice and easy to slower than normal. 1.9 Fish Hold The forward fish hold was positioned between the forecastle and the wheel-house. The fish hold hatch coaming was about 1m high. An aluminium hatch cover measuring 1.5mx 2.5m was fitted with a 0.45mx 0.45m access hatch to gain entry to the fish hold. The securing arrangement comprised a length of rope stretched over the hatch cover and secured to a pad eye/ring on either side of the hatch coaming. Neither the cover nor the access hatch was secured at the time of the accident. The after fish hold was located aft of the wheel-house and contained a small quantity of ice and stores. The hatch coaming was 250mm high. The coaming was fitted with a 1.2mx1.2m aluminium cover and the latter with a 0.45mx 0.45m access hatch. Their securing arrangement was similar to that of the forward hold. Both openings to the after fish hold were secured at the time of the accident. 1.10 Fish Hold Penning Consistent with good seamanship practice, although not required by regulations, the fish holds on board the PACIFIC BANDIT were divided into pens with portable longitudinal and transverse pen boards to prevent the movement of fish carried in bulk. The forward fish hold was divided into nine pens and the after fish hold into four pens. The fore-and-aft and athwartship pen boards in the forward fish hold did not extend to the deckhead but were about 450mm below it, and the stowed fish extended some 150mm above the pen boards. 1.11 Fish-loading Deck Scuttles The forward fish hold was fitted with four slightly raised fish-loading scuttles on deck (hereinafter referred to as the deck scuttles), two each on the port and starboard sides, a pair forward and a pair abaft the main hatchway. The scuttles were used to load fish into the hold, and each scuttle was provided with an aluminium watertight cover secured by a single-action, key-operated closing mechanism. The covers were not hinged, nor were they permanently attached by a chain to the vessel's structure as required by the regulations. According to the ship's crew, the seals of the forward deck scuttles on the forward fish hold were watertight, but the seals of the deck scuttles at the after end of the hold were not. The after deck scuttles allowed water accumulated on deck to leak into the forward fish hold. The crew was aware of this and reportedly had discussed replacing the seals at the end of the trip. 1.11.1 Shipboard Practice--Securing of Deck Scuttles The general practice on board this vessel was for the person in attendance to secure the deck scuttle following its use. The skipper would then confirm with the crew that the scuttles were secured. On this occasion, the engineer had secured the deck scuttle and had so informed the skipper. 1.12 Poundboards on Deck To facilitate sorting of the catch prior to loading it into the hold, the vessel was fitted with two tiers of 250mm-high poundboards on deck to prevent fish from sliding overboard. The poundboards were not provided with the means required by regulations to facilitate rapid and effective drainage of water accumulated in the pounds. In this instance, the poundboards were left in place until after the weather had deteriorated and the shipped sea water could no longer drain rapidly from the deck. 1.12.1 Freeing Ports The freeing ports aboard the PACIFIC BANDIT were similar to those seen on board a similar vessel, the TWINJ. They were arranged in the bulwarks on the main deck. The gap between the top edge of the sheer strake and the bottom end of the bulwark plating on the main deck acted as freeing ports for the vessel. To facilitate rapid and effective drainage of water from the deck, four additional freeing ports had been fitted: two measuring about 0.5mx 0.5m in way of the forward fish hold, one on each of the port and starboard sides; and two measuring about 0.3mx 0.3m in way of the after fish hold, one on each side. 1.13 Fish Loading Procedure After each set, the net was hauled on board, and the catch was emptied into the pounds (locally referred to as checkers) on deck and sorted. A deck scuttle would be opened and a crew member, positioned in the hold, would ice the fish as it was being dumped into the compartment. 1.14 Bilge Pumping Arrangement The vessel's bilge pumping arrangement comprised a self-priming power bilge pump connected by 38mm-diameter piping to suctions in the forward fish hold, the engine-room, and the after fish hold. The arrangement in the lazaret permitted water to drain into the engine-room bilge from where it could be pumped overboard. Reportedly, no problem was encountered with the pumping arrangement. 1.15 Other Watertight/Weathertight Openings A watertight deck scuttle installed flush on the main deck provided access to the lazaret. 1.16 Weather and Tidal Information 1.16.1 Weather Forecast and Experienced The marine weather forecast issued by the Pacific Weather Centre of Environment Canada at 1645, Friday 10February 1995, called for north-west winds at 5 to 15knots (kn) and 1 to 2m seas; the outlook called for strong northerlies. The 2245 forecast called for winds to increase overnight to 15 to 25kn, and 2 to 3m seas. The weather experienced by the vessel is consistent with that recorded at the nearest weather recording station at La Prouse Bank, B.C. At the time of the accident, the wave height was about 2m and the wind was northerly at 15 to 20kn. 1.16.2 Current and Tide High water was calculated to occur at Tofino at 2253, 10February 1995, with a height of 3.05m above chart datum, and low water at 0418 the following morning with a height of 1.95m above chart datum. Maximum flood occurs 3hours 50minutes before high water at Tofino(4). 1.17 Life-saving Equipment There is conflicting evidence with respect to the life-saving equipment information as recorded in the SIC29 and SIRSII, and the equipment on board the PACIFIC BANDIT at the time of the accident. The conflicting information is as follows: The regulations made pursuant to the Canada Shipping Act as well as those made pursuant to the British Columbia Workers' Compensation Board Act require that the master ensure that the crew understands the use of life-saving equipment and is aware of its location. In this instance, the cook and deck-hand did not know that the lifejackets or the immersion suits were located in the forecastle accommodation, nor did they consider donning them. No emergency drill had been practiced since the crew members who survived had joined the vessel. 1.17.1 Inflatable Liferaft Additional Lashings to Secure the Liferaft The inflatable liferaft was positioned in a cradle on the port side of the cabin-top and secured to the deck by securing straps. Additional rope lashings were used to further secure the liferaft to the deck, but no quick-release mechanism such as a Senhouse slip was used. There was no knife or other means of cutting the lashing ready to hand, and the engineer had to return below-deck to get a knife. Before he could finish cutting the lashings, the knife blade broke, but he eventually managed to launch the liferaft when the vessel was on her beam-ends. The regulatory minimum length of the inflatable liferaft's painter is 15m, but some manufacturers provide a longer painter. The inboard end of the painter is connected to the pull/operating cable which activates the (non-toxic) gas cylinder that inflates the liferaft. The whole length of the painter has to be hauled out of the canister before the liferaft can be inflated. As was the case in this occurrence, there have been other instances of crew members finding themselves in water without lifejackets before the liferaft could be launched or inflated. In the 2 to 3m seas, the skipper, who was not wearing a lifejacket, had to remain afloat and hold on to the liferaft with one hand while hauling on the painter with his other hand. Once on board the liferaft, the skipper could not find the knife inside the liferaft in darkness to cut the painter attaching the liferaft to the capsized vessel. He therefore began chewing through the nylon painter. The engineer completed the task some 20 minutes later, after the skipper had broken one of his teeth. The six-person Beaufort liferaft had been serviced on 01June 1994, some 16 days before the SIC29 was issued. However, when the liferaft was deployed, the following defects were reported: - the flashlight, which was in the sealed A pack, did not function; and - the liferaft's dome light was unserviceable. A parachute flare was successfully deployed to attract the attention of a rescue helicopter, and the surviving crew members were rescued shortly thereafter. Entrance Covers Securing Arrangement The entrance to the liferaft was provided with entrance covers that could be closed and secured in place by tie tapes. However, in the cold weather, the survivors had difficulty using the entrance tie tapes because their fingers were numb. 1.17.2 Malfunction of Liferaft Equipment According to the servicing depot, industrial-type batteries are used for the flashlight and are always replaced at the time of annual servicing of the liferaft. The batteries for the liferaft dome light are water-activated. As the contacts, when exposed to sea water, form a switch that turns the power on, safety caps are used to cover the contacts to protect against premature operation. The safety caps are attached to the grab line on the sides of the liferaft by a lanyard, such that the cap will automatically be dislodged as the liferaft inflates. A post-occurrence inspection of the liferaft revealed that: the batteries for the dome light were dead; corrosion and broken wiring in the male-female plug for the batteries to the dome light rendered the plug unserviceable; and there was no lanyard attached to the safety caps. The unit was sent to the TSB Engineering Laboratory for analysis where it was examined and tested. The laboratory report(5) concluded that the fractured surfaces showed heavy deposits of corrosion products (cuprous chloride) which indicates that the corrosion had occurred over an extended period of time and strongly suggests that the conductor was fractured prior to the deployment of the liferaft. 1.17.3 Emergency Position Indicating Radio Beacon (EPIRB) 1.18 Cold Water Survival The sea water temperature in the immediate area was not recorded; however, the average temperature of sea water west of Vancouver Island is 7C. Scientific studies of cooling rates on an average adult person holding still in ocean water of 7C and wearing a standard lifejacket and light clothing show a predicted survival time of about two hours. Extra body fat can increase survival time. The missing deck-hand was described as being 1.82m tall and weighing approximately 82kg. He was reportedly in good health and an excellent swimmer. He was not wearing a lifejacket or an approved personal flotation device (PFD).